Geographic Absence of Home-Based Palliative Care in Japan: Do Outpatient Services Cover These Areas? A Nationwide Ecological Study

Abstract

Objective: To evaluate geographic access to home-based palliative care across Japan’s 335 secondary medical areas (SMAs) and whether outpatient palliative care remains reachable where home-based services are absent. Design: Nationwide cross-sectional ecological study. Setting: All 335 SMAs in Japan. Specialist palliative care in both delivery modes is institutionally anchored to cancer care. Methods: Using the enhanced 2-step floating catchment area (E2SFCA) method, accessibility scores and Gini coefficients were calculated for home-based and outpatient palliative care. SMAs with effectively zero access (median accessibility score of zero) were classified a priori (home-based, outpatient, or both absent); the remaining SMAs were classified by Ward’s clustering of 4 standardized accessibility and disparity indicators. Correlates of service absence were explored by logistic regression. Results: Home-based accessibility was concentrated in metropolitan areas (Moran’s I = 0.664) and effectively zero in 63 SMAs (18.8%). Outpatient care remained geographically reachable in 38 of these, whereas 25 SMAs (7.5%) lacked both services. These 25 areas were the oldest (median 40.4% aged ≥65 years), had the highest shares of non-residential land and of older residents living alone, and lacked palliative care units. The remaining 261 SMAs formed 2 clusters: C1, low access–high disparity (n = 69), and C2, higher access–low disparity (n = 192). Conclusion: Home-based palliative care is geographically absent in nearly 1 in 5 SMAs; outpatient care remains reachable in most of these, but 25 areas lack both. These aging, geographically constrained areas, where many older residents live alone, should receive priority consideration in developing home-based palliative care.